What is Mentalisation-Based Treatment?

Introduction

Mentalisation-based treatment (MBT) is an integrative form of psychotherapy, bringing together aspects of psychodynamic, cognitive-behavioural, systemic and ecological approaches. MBT was developed and manualised by Peter Fonagy and Anthony Bateman, designed for individuals with borderline personality disorder (BPD). Some of these individuals suffer from disorganised attachment and failed to develop a robust mentalisation capacity. Fonagy and Bateman define mentalisation as the process by which we implicitly and explicitly interpret the actions of oneself and others as meaningful on the basis of intentional mental states. The object of treatment is that patients with BPD increase their mentalisation capacity, which should improve affect regulation, thereby reducing suicidality and self-harm, as well as strengthening interpersonal relationships.

More recently, a range of mentalisation-based treatments, using the “mentalising stance” defined in MBT but directed at children (MBT-C), families (MBT-F) and adolescents (MBT-A), and for chaotic multi-problem youth, AMBIT (adaptive mentalisation-based integrative treatment) has been under development by groups mainly gravitating around the Anna Freud National Centre for Children and Families.

The treatment should be distinguished from and has no connection with mindfulness-based stress reduction (MBSR) therapy developed by Jon Kabat-Zinn.

Goals

The major goals of MBT are:

  • Better behavioural control.
  • Increased affect regulation.
  • More intimate and gratifying relationships.
  • The ability to pursue life goals.

This is believed to be accomplished through increasing the patient’s capacity for mentalisation in order to stabilise the client’s sense of self and to enhance stability in emotions and relationships.

Focus of Treatment

A distinctive feature of MBT is placing the enhancement of mentalising itself as focus of treatment. The aim of therapy is not developing insight, but the recovery of mentalising. Therapy examines mainly the present moment, attending to events of the past only insofar as they affect the individual in the present. Other core aspects of treatment include a stance of curiosity, partnership with the patient rather than an ‘expert’ type role, monitoring and regulating emotional arousal, and identifying the affect focus. Transference in classical understanding of this term is not included in the MBT model. MBT does encourage consideration of the patient-therapist relationship, but without necessarily generalising to other relationships, past or present.

Treatment Procedure

MBT should be offered to patients twice per week with sessions alternating between group therapy and individual treatment. During sessions the therapist works to stimulate or nurture mentalising. Particular techniques are employed to lower or raise emotional arousal as needed, to interrupt non-mentalising and to foster flexibility in perspective-taking. Activation occurs through the elaboration of current attachment relationships, the therapist’s encouragement and regulation of the patient’s attachment bond with the therapist and the therapist’s attempts to create attachment bonds between members of the therapy group.

Mechanisms of Change

The safe attachment relationship with the therapist provides a relational context in which it is safe for the patient to explore the mind of the other. Fonagy and Bateman have recently proposed that MBT (and other evidence-based therapies) works by providing ostensive cues that stimulate epistemic trust. The increase in epistemic trust, together with a persistent focus on mentalising in therapy, appear to facilitate change by leaving people more open to learning outside of therapy, in the social interactions of their day-to-day lives.

Efficacy

Fonagy, Bateman, and colleagues have done extensive outcome research on MBT for borderline personality disorder. The first randomised, controlled trial was published in 1999, concerning MBT delivered in a partial hospital setting. The results showed real-world clinical effectiveness that compared favourably with existing treatments for BPD. A follow-up study published in 2003 demonstrated that MBT is cost-effective. Encouraging results were also found in an 18-month study, in which subjects were randomly assigned to an outpatient MBT treatment condition versus a structured clinical management (SCM) treatment. The lasting efficacy of MBT was demonstrated in an 8-year follow-up of patients from the original trial, comparing MBT versus treatment as usual. In that research, patients who had received MBT had less medication use, fewer hospitalisations and longer periods of employment compared to patients who received standard care. Replication studies have been published by other European investigators. Researchers have also demonstrated the effectiveness of MBT for adolescents as well as that of a group-only format of MBT.

What is Transference Focused Psychotherapy?

Introduction

Transference focused psychotherapy (TFP) is a highly structured, twice-weekly modified psychodynamic treatment based on Otto F. Kernberg’s object relations model of borderline personality disorder.

It views the individual with borderline personality organisation (BPO) as holding unreconciled and contradictory internalised representations of self and significant others that are affectively charged. The defence against these contradictory internalised object relations leads to disturbed relationships with others and with self. The distorted perceptions of self, others, and associated affects are the focus of treatment as they emerge in the relationship with the therapist (transference). The treatment focuses on the integration of split off parts of self and object representations, and the consistent interpretation of these distorted perceptions is considered the mechanism of change.

TFP has been validated as an efficacious treatment for borderline personality disorder (BPD), though too few studies have been conducted to allow firm conclusions about its value. TFP is one of a number of treatments that may be useful in the treatment of BPD; however, in a study which compared TFP, dialectical behaviour therapy, and modified psychodynamic supportive psychotherapy, only TFP was shown to change how patients think about themselves in relationships.

Borderline Personality Disorder

TFP is a treatment for borderline personality disorder (BPD). Patients with BPD are often characterised by intense affects, stormy relationships, and impulsive behaviours. Due to their high reactivity to environmental stimuli, patients with BPD often experience dramatic and short-lived shifts in their mood, alternating between experiences of euphoria, depression, anxiety, and nervousness. Patients with BPD often experience intolerable feelings of emptiness that they attempt to fill with impulsive and self-damaging behaviours, such as substance abuse, risky sexual behaviour, uncontrolled spending, or binge eating. Further, patients with BPD often exhibit recurrent suicidal behaviours, gestures, or threats. Under intense stress patients with BPD may exhibit transient dissociative or paranoid symptoms.

Theoretical Model of Borderline Personality

According to an object relations model, in normal psychological development mental templates of oneself in relation to others, or object representations, become increasingly more differentiated and integrated. The infant’s experience, initially organised around moments of pain (“I am uncomfortable and in need of someone to care for me”) and pleasure (“I am now being soothed by someone and feel loved”), become increasingly integrated and differentiated mental templates of oneself in relation to others. These increasingly mature representations allow for the realistic blending of good and bad, such that positive and negative qualities can be integrated into a complex, multifaceted representation of an individual (“Although she is not caring for me at this moment, I know she loves me and will do so in the future”). Such integrated representations allow for the tolerance of ambivalence, difference, and contradiction in oneself and others.

For Kernberg the degree of differentiation and integration of these representations of self and other, along with their affective valence, constitutes personality organisation. In a normal personality organisation the individual has an integrated model of self and others, allowing for stability and consistency within one’s identity and in the perception of others, as well as a capacity for becoming intimate with others while maintaining one’s sense of self. For example, such an individual would be able to tolerate hateful feelings in the context of a loving relationship without internal conflict or a sense of discontinuity in the perception of the other. In contrast, in Borderline Personality Organisation (BPO), the lack of integration in representations of self and other leads to the use of primitive defence mechanisms (e.g. splitting, projective identification, dissociation), identity diffusion (inconsistent view of self and others), and unstable reality testing (inconsistent differentiation between internal and external experience). Under conditions of high stress, borderline patients may fail to appreciate the “whole” of the situation and interpret events in catastrophic and intensely personal ways. They fail to discriminate the intentions and motivations of the other and thus, perceive only threat or rejection. Thus thoughts and feelings about self and others are split into dichotomous experiences of good or bad, black or white, all or nothing.

Goals

The major goals of TFP are to reduce suicidality and self-injurious behaviours, and to facilitate better behavioural control, increased affect regulation, more gratifying relationships, and the ability to pursue life goals. This is believed to be accomplished through the development of integrated representations of self and others, the modification of primitive defensive operations, and the resolution of identity diffusion that perpetuate the fragmentation of the patient’s internal representational world.

Treatment Procedure

Contract

The treatment begins with the development of the treatment contract, which consists of general guidelines that apply for all clients and of specific items developed from problem areas of the individual client that could interfere with the therapy progress. The contract also contains therapist responsibilities. The client and the therapist must agree to the content of the treatment contract before the therapy can proceed.

Therapeutic Process

TFP consists of the following three steps:

  • Diagnostic description of a particular internalised object relation in the transference.
  • Diagnostic elaboration of the corresponding self and object representation in the transference, and of their enactment in the transference/countertransference.
  • Integration of the split-off self representations, leading to an integrated sense of self and others which resolves identity diffusion.

During the first year of treatment, TFP focuses on a hierarchy of issues:

  • Containment of suicidal and self-destructive behaviours.
  • Various ways of destroying the treatments.
  • Identification and recapitulation of dominant object relational patterns (from unintegrated and undifferentiated affects and representations of self and others to a more coherent whole).

In this treatment, the analysis of the transference is the primary vehicle for the transformation of primitive (e.g. split, polarised) to advanced (e.g. complex, differentiated and integrated) object relations. Thus, in contrast to therapies that focus on the short-term treatment of symptoms, TFP has the ambitious goal of not just changing symptoms, but changing the personality organisation, which is the context of the symptoms. To do this, the client’s affectively charged internal representations of previous relationships are consistently interpreted as the therapist becomes aware of them in the therapeutic relationship, that is, the transference. Techniques of clarification, confrontation, and interpretation are used within the evolving transference relationship between the patient and the therapist.

In the psychotherapeutic relationship, self and object representations are activated in the transference. In the course of the therapy, projection and identification are operating, i.e. devalued self-representations are projected onto the therapist whilst the client identifies with a critical object representation. These processes are usually connected to affective experiences such as anger or fear.

The information that emerges within the transference provides direct access to the individual’s internal world for two reasons. First, it is observable by both therapist and patient simultaneously so that inconsistent perceptions of the shared reality can be discussed immediately. Second, the perceptions of shared reality are accompanied by affect whereas the discussion of historical material can have an intellectualised quality and be thus less informative.

TFP emphasizes the role of interpretation within psychotherapy sessions. As the split-off representations of self and other get played out in the course of the treatment, the therapist helps the patient to understand the reasons (the fears or the anxieties) that support the continued separation of these fragmented senses of self and other. This understanding is accompanied by the experience of strong affects within the therapeutic relationship. The integration of the split and polarized concepts of self and others leads to a more complex, differentiated, and realistic sense of self and others that allows for better modulation of affects and in turn clearer thinking. Therefore, as split-off representations become integrated, patients tend to experience an increased coherence of identity, relationships that are balanced and constant over time and therefore not at risk of being overwhelmed by aggressive affect, a greater capacity for intimacy, a reduction in self-destructive behaviours, and general improvement in functioning.

Mechanisms of Change

In TFP, hypothesised mechanisms of change derive from Kernberg’s developmentally based theory of Borderline Personality Organisation, conceptualised in terms of unintegrated and undifferentiated affects and representations of self and other. Partial representations of self and other are paired and linked by an affect in mental units called object relation dyads. These dyads are elements of psychological structure. In borderline pathology, the lack of integration of the internal object relations dyads corresponds to a ‘split’ psychological structure in which totally negative representations are split off/segregated from idealised positive representations of self and other (seeing people as all good or all bad). The putative global mechanism of change in patients treated with TFP is the integration of these polarised affect states and representations of self and other into a more coherent whole.

Empirical Support

Preliminary Research

In early research studying the efficacy of a year-long TFP, suicide attempts were significantly reduced during treatment. Additionally, the physical condition of the patients was significantly improved. When the researchers compared the treatment year to the year prior, it was found that there was a significant reduction in psychiatric hospitalisations and days spent as inpatients in psychiatric hospitals. The dropout rate for the 1-year study was 19.1%, which the authors state as comparable to dropout rates in previous studies assessing the treatment of borderline individuals, including DBT research.

TFP vs. Treatment-As-Usual (TAU)

Results indicated that the TFP group experienced significant decreases in ER visits and hospitalisations during treatment year, as well as significant increases in global functioning when compared to TAU.

TFP vs. Treatment by Community Experts

A randomised clinical trial compared the outcomes of TFP or treatment by community experts for 104 borderline patients. The dropout rate was significantly higher in the community psychotherapy condition; however, the dropout rate for TFP was 38.5%, which the authors acknowledge as somewhat higher than dropout rates associated with dialectical behaviour therapy (DBT) and schema-focused therapy (SFT). The TFP group experienced significant improvement in personality organisation, psychosocial functioning, and number of suicide attempts. In this study neither group was associated with a significant change in self-harming behaviours.

TFP vs. DBT vs. Supportive Treatment

Prior to treatment and at four-month intervals during treatment, patients were assessed in the following domains: suicidal behaviour, aggression, impulsivity, anxiety, depression, and social adjustment. Results indicate that patients in all three conditions showed improvement in multiple domains at the one-year mark. Only DBT and TFP were significantly associated with improvement in suicidal behaviours; however, TFP outperformed DBT in anger and impulsivity improvement. Overall, participation in TFP predicted significant improvement in 10 of the 12 variables across the 6 domains, DBT in 5 of 12, and ST in 6 of the 12 variables.

TFP vs. Schema Focused Therapy

Significant improvements were found in both treatment groups on DSM-IV BPD criteria and on all four of the study’s outcome measures (borderline psychopathology, general psychopathology, quality of life, and TFP/SFT personality concepts) after 1-, 2-, and 3-years. Schema focused therapy (SFT, or schema therapy as it is now commonly known) was associated with a significantly higher retention rate. After three years of treatment, schema therapy patients showed greater increases in quality of life, and significantly more schema therapy patients recovered or showed clinical improvement on the BPD Severity Index, fourth version. However, the TFP cell contained more suicidal patients and showed less adherence casting doubt on a direct comparison between treatments. The schema therapy group improved significantly more than the TFP group with respect to relationships, impulsivity, and parasuicidal/suicidal behaviour although many of the alliance ratings were made after dropout. It was concluded that schema therapy was significantly more effective than TFP on all outcome measures assessed during the study. A follow-up of this study concluded that both clients and therapists rated therapeutic alliance higher in schema therapy than in TFP.

Book: DBT Skills Training Manual

Book Title:

DBT Skills Training Manual.

Author(s): Marsha M Linehan.

Year: 2015.

Edition: Second (2nd).

Publisher: Guildford Press.

Type(s): Hardcover, Paperback, and Kindle.

Synopsis:

From Marsha M. Linehan – the developer of dialectical behaviour therapy (DBT) – this comprehensive resource provides vital tools for implementing DBT skills training. The reproducible teaching notes, handouts, and worksheets used for over two decades by hundreds of thousands of practitioners have been significantly revised and expanded to reflect important research and clinical advances. The book gives complete instructions for orienting clients to DBT, plus teaching notes for the full range of mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance skills. Handouts and worksheets are not included in the book; purchasers get access to a Web page where they can download and print all the handouts and worksheets discussed, as well as the teaching notes. The companion volume is available separately: DBT Skills Training Handouts and Worksheets, Second Edition.

New to This Edition

  • Handouts and worksheets (available online and in the companion volume) have been completely revised and dozens more added – more than 225 in all.
  • Each module has been expanded with additional skills.
  • Multiple alternative worksheets to tailor treatment to each client.
  • More extensive reproducible teaching notes (provided in the book and online), with numerous clinical examples.
  • Curricula for running skills training groups of different durations and with specific populations, such as adolescents and clients with substance use problems.
  • Linehan provides a concise overview of “How to Use This Book.”

See also DBT Skills Training Handouts and Worksheets, Second Edition, a spiral-bound 8 1/2″ x 11″ volume containing all of the handouts and worksheets and featuring brief introductions to each module written expressly for clients.

Book: The Dialectical Behaviour Therapy Skills Workbook

Book Title:

The Dialectical Behaviour Therapy Skills Workbook: Practical DBT Exercises for Learning Mindfulness, Interpersonal Effectiveness, Emotion Regulation, and Distress Tolerance.

Author(s): Matthew McKay and Jeffrey C. Wood.

Year: 2019.

Edition: Second (2nd).

Publisher: New Harbinger.

Type(s): Paperback and Kindle.

Synopsis:

A clear and effective approach to learning evidence-based DBT skills-now in a fully revised and updated second edition.

Do you have trouble managing your emotions? First developed by Marsha M. Linehan for treating borderline personality disorder, dialectical behaviour therapy (DBT) has proven effective as treatment for a range of other mental health problems, and can greatly improve your ability to handle distress without losing control and acting destructively.

However, to make use of these techniques, you need to build skills in four key areas: distress tolerance, mindfulness, emotion regulation, and interpersonal effectiveness.

The Dialectical Behavior Therapy Skills Workbook, a collaborative effort from three esteemed authors, offers
evidence-based, step-by-step exercises for learning these concepts and putting them to work for real and lasting change. Start by working on the introductory exercises and, after making progress, move on to the advanced-skills chapters.
Whether you’re a mental health professional or a general reader, you’ll benefit from this clear and practical guide to better managing your emotions.

This fully revised and updated second edition also includes new chapters on cognitive rehearsal, distress tolerance, and self-compassion. Once you have completed the exercises in this book and are ready to move on to the next level, check out the authors’ new book, The New Happiness Workbook.

Book: DBT Skills Training Handouts and Worksheets

Book Title:

DBT Skills Training Handouts and Worksheets.

Author(s): Marsha M Linehan.

Year: 2014.

Edition: Second (2nd).

Publisher: Guildford Press.

Type(s): Paperback and Kindle.

Synopsis:

Featuring more than 225 user-friendly handouts and worksheets, this is an essential resource for clients learning dialectical behaviour therapy (DBT) skills, and those who treat them. All of the handouts and worksheets discussed in Marsha M. Linehan’s DBT Skills Training Manual, Second Edition, are provided, together with brief introductions to each module written expressly for clients.

Originally developed to treat borderline personality disorder, DBT has been demonstrated effective in treatment of a wide range of psychological and emotional problems. No single skills training programme will include all of the handouts and worksheets in this book; clients get quick, easy access to the tools recommended to meet their particular needs. The 8 1/2″ x 11″ format and spiral binding facilitate photocopying. Purchasers also get access to a Web page where they can download and print additional copies of the handouts and worksheets.

Mental health professionals, see also the author’s DBT Skills Training Manual, Second Edition, which provides complete instructions for teaching the skills. Also available: Cognitive-Behavioural Treatment of Borderline Personality Disorder, the authoritative presentation of DBT, and Linehan’s instructive skills training videos for clients – Crisis Survival Skills: Part One, Crisis Survival Skills: Part Two, From Suffering to Freedom, This One Moment, and Opposite Action.

Refer to DBT Skills Training book.

Book: Cognitive-Behavioural Treatment of Borderline Personality Disorder

Book Title:

Cognitive-Behavioural Treatment of Borderline Personality Disorder (Diagnosis and Treatment of Mental Disorders).

Author(s): Marsha M. Linehan.

Year: 1993.

Edition: First (1st).

Publisher: Guildford Press.

Type(s): Hardcover and Kindle.

Synopsis:

For the average clinician, individuals with borderline personality disorder (BPD) often represent the most challenging, seemingly insoluble cases. This volume is the authoritative presentation of dialectical behaviour therapy (DBT), Marsha M. Linehan’s comprehensive, integrated approach to treating individuals with BPD. DBT was the first psychotherapy shown in controlled trials to be effective with BPD. It has since been adapted and tested for a wide range of other difficult-to-treat disorders involving emotion dysregulation. While focusing on BPD, this book is essential reading for clinicians delivering DBT to any clients with complex, multiple problems.

Companion volumes: The latest developments in DBT skills training, together with essential materials for teaching the full range of mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance skills, are presented in Linehan’s DBT Skills Training Manual, Second Edition, and DBT Skills Training Handouts and Worksheets, Second Edition. Also available: Linehan’s instructive skills training videos for clients – Crisis Survival Skills: Part One, Crisis Survival Skills: Part Two, From Suffering to Freedom, This One Moment, and Opposite Action.

Book: Emotion Efficacy Therapy

Book Title:

Emotion Efficacy Therapy: A Brief, Exposure-Based Treatment for Emotion Regulation Integrating ACT and DBT.

Author(s): Matthew McKay (PhD) and Aprilia West (PSyD, MT).

Year: 2016.

Edition: First (1st).

Publisher: New Harbinger.

Type(s): Paperback and Kindle.

Synopsis:

If you treat clients with emotion regulation disorders – including depression, anxiety, post-traumatic stress disorder (PTSD), bipolar disorder, and borderline personality disorder (BPD) – you know how important it is for these clients to take control of their emotions and choose their actions in accordance with their values. To help, emotion efficacy therapy (EET) provides a new, theoretically-driven, contextually-based treatment that integrates components from acceptance and commitment therapy (ACT) and dialectical behaviour therapy (DBT) into an exposure-based protocol. In doing so, EET targets the transdiagnostic drivers of experiential avoidance and distress intolerance to increase emotional efficacy.

This step-by-step manual will show you how to help your clients confront and accept their pain, and learn to apply new adaptive responses to emotional triggers. Using a brief treatment that lasts as little as eight weeks, you will be able to help your clients understand and develop a new relationship with their emotions, learn how to have mastery over their emotional experience, practice values-based action in the midst of being emotionally triggered, and stop intense emotions from getting in the way of creating the life they want.

Using the transdiagnostic, exposure-based approach in this book, you can help your clients manage difficult emotions, curb negative reactions, and start living a better life. This book is a game changer for emotion exposure treatment!

Book: Working Effectively with ‘Personality Disorder’

Book Title:

Working Effectively with ‘Personality Disorder’: Contemporary and Critical Approaches to Clinical and Organisational Practice.

Author(s): Jo Ramsden, Sharon Prince, and Julia Blazdell (Editors).

Year: 2020.

Edition: First (1st).

Publisher: Luminate.

Type(s): Paperback and Kindle.

Synopsis:

The history of personality disorder services is problematic to say the least. The very concept is under heavy fire, services are often expensive and ineffective, and many service users report feeling that they have been deceived, stigmatised or excluded. Yet while there are inevitably serious (and often destructive) relational challenges involved in the work, creative networks of learning do exist – professionals who are striving to provide progressive, compassionate services for and with this client group.

Working Effectively with Personality Disorder shares this knowledge, articulating an alternative way of working that acknowledges the contemporary debate around diagnosis, reveals flawed assumptions underlying current approaches, and argues for services that work more positively, more holistically and with a wider and more socially focused agenda.

Book: Psychiatry and Mental Health

Book Title:

Psychiatry and Mental Health: A guide for counsellors and psychotherapists.

Author(s): Rachel Freeth.

Year: 2020.

Edition: First (1st).

Publisher: PCCS Books.

Type(s): Paperback and Kindle.

Synopsis:

Increasingly, counsellors and psychotherapists are working with people who have been diagnosed with a mental disorder and are required to understand and navigate the mental health system. Counselling training rarely covers the fields of psychiatry and mental disorder in detail and there are few reliable resources on which they can draw.

This comprehensive guide to psychiatry and the mental health system, written by a psychiatrist and counsellor, aims to fill that gap.

The book is intended for counsellors and psychotherapists but will be helpful to others in the mental health field. It explains the organisation and delivery of mental health services in the UK, the theories and concepts underpinning the practice of psychiatry, the medical model of psychiatric diagnosis and treatment, the main forms of mental disorder, how to work therapeutically with people with a diagnosed mental disorder and how to work with risk of suicide and self-harm.

The text is designed to support continuing professional development and training and includes activities, points for learning/discussion and comprehensive references.

Book: Mental Health: Personalities

Book Title:

Mental Health: Personalities: Personality Disorders, Mental Disorders & Psychotic Disorders (Bipolar, Mood Disorders, Mental Illness, Mental Disorders, Narcissist, Histrionic, Borderline Personality).

Author(s): Carol Franklin.

Year: 2015.

Edition: Third (3rd).

Publisher: CreateSpace Independent Publishing Platform.

Type(s): Paperback and Kindle.

Synopsis:

At some point in your life you will probably start to think you are losing your mind, or that someone you know is in danger of losing theirs. The truth is that modern life is extremely stressful; there are many demands on your time and never enough hours in the day.

However, being at the end of your tether, worn out and overwhelmed is not the same as having a mental disorder. In fact mental health covers a wide range of illnesses including those which most people are aware of, such as Schizophrenia (which is classed as a psychotic disorder). What you may not be aware of is the number of people who have personality disorders and the reasons for these disorders. Most people are not diagnosed until into their twenties and symptoms will naturally reduce in their forties or fifties.

Knowing the difference between the various mental illnesses is essential to ensure you know when a friend or loved one needs professional help as opposed to just your care and attention. This book will guide you through the differences between personality disorders, mental disorders and psychotic disorders.

It will help you to understand the different elements of a personality and how you can test your friends to find out which personality type they are. It will even enlighten you as to the basic traits of each of the sixteen personality types, according to the Myers Briggs Personality test.

Reading this book will enlighten you as to the names and details of the nine main personality disorders, how to recognize the symptoms of each of these disorders and the best way to treat them. It is important to use this book as a guide to understanding these illnesses and to learn the best way to help and support anyone you know who is suffering from a personality disorder. However, a diagnosis must always be confirmed by a medical professional who will ensure treatment is available.

Many people who have a mental health issue will not recognise the issue in themselves; this book will ensure you understand each condition and can help your loved one to get the appropriate treatment.

Everyone deserves the chance to have a happy, fulfilling and balanced life. Read this and help those around you have that chance!